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Journal Club

Journal Club. Background. AKI 2 - 7% of hospitalized patients > 35 % of ICU patients RRT in 5 – 6% of ICU patients Morbidity and mortality rates > 50%. Background. RRT in AKI When to start? What dose? What method?. Background. BUN = 104 60. Background.

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Journal Club

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  1. Journal Club

  2. Background • AKI • 2 - 7% of hospitalized patients • > 35 % of ICU patients • RRT in 5 – 6% of ICU patients • Morbidity and mortality rates > 50%

  3. Background • RRT in AKI • When to start? • What dose? • What method?

  4. Background BUN = 104 60

  5. Background 45ml/kg/hr 35 ml/kg/hr 20 ml/kg/hr

  6. Background

  7. Background

  8. Background

  9. Background

  10. Objectives • Test the hypothesis • More intensive RRT is associated with improved survival in ICU patients with AKI

  11. Methods • Eligible Patients • Critically ill • 18 yrs or older • AKI consistent with ATN, and requiring RRT • Failure of one or more other organs, or sepsis • No more than • 1 IHD or SLED prior to randomization • 24 hrs of CRRT prior to randomization

  12. Methods • Randomization • SOFA cardiovascular score • Oliguria ( < 20 ml/hr for 24 hrs)

  13. SOFA Cardiovascular • MAP < 70 mm/Hg, 1 • dopamine <= 5 or dobutamine (any dose), 2 • dop > 5 OR epi <= 0.1 OR nor <= 0.1, 3 • dop > 15 OR epi > 0.1 OR nor > 0.1, 4 • (vasopressor drug doses are in mcg/kg/min)

  14. Methods • Interventions • SOFA cardiovascular score of 0 - 2 received IHD • SOFA cardiovascular score of 3 – 4 received SLED or CRRT (site specific) • Transition based on CV status

  15. Methods • Intensive therapy • 6 IHD or SLED per week (spKt/v 1.2 to 1.4) • CVVHDF with 35 ml/kg/hr of effluent • “Standard” therapy • 3 IHD or SLED per week • CVVHDF with 20 ml/kg/hr of effluent • Additional UF was allowed

  16. Methods • Assigned RRT was provided for up to 28 days post randomization, unless • Recovery of renal fxn • Discharge from acute care • Withdrawal of care • Death

  17. Methods • Primary end point • All cause mortality at 60 days • Secondary end points • In-hospital death • Recovery of kidney function • Additional end points • Duration of RRT • Length of ICU stay • Days free of non-renal organ failure • Pt returned to ‘home’

  18. Conclusion • There was no difference in 60 day mortality or rate of recovery of renal function between the two groups. • Intensive therapy resulted in more episodes of hypotension and electrolyte abnormalities

  19. Discussion • Multicenter, randomized, prospective • Study design consistent with clinical practice

  20. Discussion • More SLED in the high intensity group • Preponderance of male patients • Exclusion of CKD, ESRD, or renal txp pts • Use of predilution • Changing modalities (consistent with clinical practice)

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